Pros & Cons: Long-Acting Reversible Contraceptives (LARC)

While the benefits of birth control are obvious, each method has its drawbacks. Keeping up with daily birth control pills, for example, can be a real hassle, and making a trip to the doc every three months for a Depo-Provera shot may be inconvenient. Plus, several methods don’t have high enough success rates to provide true peace of mind about the risk of pregnancy, and others require a waiting period before a woman can get pregnant when she chooses to.

One particular type of birth control bypasses many of those issues. Long-acting reversible contraceptives (LARCs) became available in 1968 with the introduction of the first intrauterine devices (IUDs). An IUD is a tiny device containing either copper or progestin (a hormone similar to the natural hormone progesterone) that is inserted into the uterus. Contraceptive implants, the other type of LARC, are progestin-based and involve tiny rods about the size of a matchstick inserted just under the skin of the arm.

Benefits of LARCs

One of the reasons LARCs are so appealing is that they are effective — fewer than 1% of women who use them become pregnant.

“They are particularly effective when compared to other forms of contraception because they remove a patient’s need to participate in regular action to maintain her birth control — no need for remembering to take a pill, take a shot, replace a patch or insert a device into your vagina,” explains Samantha L. Wiegand, MD, a maternal-fetal medicine specialist with Premier Health’s Premier Physician Network at Miami Valley Hospital in Dayton, Ohio.

“Additional benefits include cost effectiveness, few contraindications, few side effects, and privacy, and they are rapidly reversible.” Another appealing feature of LARCs is that the newer ones generally last between 3 to 5 years. Older copper IUDs tend to last even longer — 8 to 10 years. IUDs containing the progesterone hormone levonorgestrel — which last up to five years — may also reduce menstrual pain and bleeding, anemia and endometrial hyperplasia (that is, pre-cancer).

The Cons

It’s important to keep in mind that while LARCs are excellent at preventing pregnancies, they offer no protection against sexually transmitted diseases. That’s why many health care providers suggest using condoms along with LARCs to offer dual protection.

“LARCs are an excellent choice for any woman of reproductive age who desires reliable contraception,” says Dr. Wiegand, although there are some exceptions. For contraceptive implants, such as Nexplanon and Implanon, these include pregnancy, undiagnosed uterine bleeding, progesterone-sensitive cancer and possibly active liver disease.

For IUDs, contraindications include pregnancy, undiagnosed uterine bleeding, progesterone-sensitive cancer (for progestin-containing IUDs), copper allergy or Wilson’s disease (for copper-containing IUDs), breast cancer (for progestin-containing IUDs), active liver disease (for progestin-containing IUDs) and severe distortion of the uterine cavity.

“Also, it is not recommended that IUDs be used in patients who have had a recent pelvic infection of any type in the past three months,” according to Craig V. Towers, MD, FACOG, professor and vice chair of obstetrics and gynecology at the University of Tennessee Medical Center in Knoxville.

“Lastly, hormonal therapy is always recommended with caution in patients with chronic medical conditions involving diabetes, hypertension and abnormal cholesterol unless they are followed closely by a medical professional in conjunction with this use,” he adds.

How They Are Implanted

Getting either an IUD or implants inserted is a fairly easy process. Both can be performed in a doctor’s office or clinic. With the IUD, your provider will first perform a pelvic exam you and ask about your medical history. You may receive local anesthesia to numb your cervix before the procedure. The provider will place a speculum into the vagina and then insert the IUD through the cervix and into the uterus. The strings that will later aid in removal of the device are then trimmed. The whole process often takes less than five minutes.

With the implant, your provider will inject a local anesthetic before inserting the device just beneath the skin with the help of a special applicator, and then will cover it with a bandage. The process takes about a minute.

Removing the LARC

Should you decide that you want to get pregnant, the good news is that IUDs and contraceptive implants are easily removable, though this requires a doctor’s visit. Once removed, your ability to become pregnant is immediate.

During a pelvic exam, a physician will use forceps to grasp the strings of an IUD and then gently remove it. This usually takes less time than insertion of the device. For contraceptive implants, the area in the arm where the rods are numbed with a local anesthetic. A small incision is made and the implant is removed with foreceps in a procedure that usually takes only a few minutes. A small bandage is applied to the spot where the incision is made.

How They Work

The implants and the progestin-based IUD release the hormone progestin, which prevents pregnancy by blocking the release of eggs from your ovaries. It also blocks sperm by thickening the mucus in your cervix.

The copper-based IUD prevents pregnancy because copper is toxic to the sperm and eggs, making it difficult for the sperm to reach the eggs.

Side Effects

“There are few adverse problems related to LARCs,” Dr. Towers states. “The primary side effect is bleeding that can range from no periods to daily spotting to sometimes heavy bleeding, but the majority of patients do not experience this and do well.” Any of the LARCs can lead to pelvic discomfort and cramping. There is a risk of pelvic infections with the IUD, but it is now lower than 1%.

Dr. Wiegand says that, for most women, the benefits of LARCs outweigh the potential risks, which also include perforation of the uterus upon insertion (fewer than one in 1,000 women experience this problem), and in 2-10% of women, the IUD moves out of the uterus (called IUD expulsion) within the first year after insertion.

Also, if pregnancy does occur while using a LARC, there is a higher risk of ectopic pregnancy (in which the egg implants outside of the uterus, usually in a fallopian tube). Other reported side effects include headache, weight gain, acne, breast tenderness, emotional lability and abdominal pain.

If you believe you may have gotten pregnant while using a LARC, call your doctor right away for guidance. If you are pregnant, they will remove the device. If your doc is unavailable and you are experiencing unusual pelvic pain and vaginal bleeding, this may indicate ectopic pregnancy, and you should visit the ER.

Although technically not a LARC, one contraceptive device you should avoid is Essure, which is actually considered a form of permanent birth control (female sterlilization). In 2017 alone, the FDA received 11,854 reports of adverse events related to the device, which is inserted into the fallopian tubes. Side effects included severe abdominal pain, tears along the fallopian tubes where Essure is inserted, cysts, tumors, fatigue and bowel control issues.

In July, Bayer, Essure’s manufactuer, announced it would stop selling the contraceptive device by the end of the year amid a drastic drop in sales. In April, the FDA announced it was heavily restricting the sale and distribution of Essure.

Staying Safe

Dr. Wiegand offers the following advice about how to keep side effects to a minimum and when to seek medical care.

  • Consider taking Advil (ibuprofen) before your appointment for IUD insertion.
  • After LARC placement, you can treat pain or cramping with ibuprofen or another over-the-counter pain reliever, and heating pads may also be helpful.
  • After IUD placement, bleeding and cramping are normal, but call your doc or seek medical attention if any of the following occur after insertion: bleeding through more than one pad per hour, severe pain, fever or signs of pregnancy.
  • Following contraceptive implant placement, seek medical help if you have pain, discharge or swelling at the insertion site, fever or signs of pregnancy.

Dr. Towers adds that “hormonal birth control options have been associated with venous thrombosis [a blood clot in a deep vein, usually in the legs], but this [usually happens in] forms that contain estrogen, and therefore this risk is minimal with the progesterone-based LARCs.” However, he cautions that if a patient using a LARC develops leg pain, she should seek medical care as quickly as possible to make sure there are no signs of venous thrombosis.

Alicia Garrett of Charleston, West Virginia, began using an IUD about a year ago, and she appreciates its high effectiveness rate and the convenience of rarely having to think about maintenance. She does keep pantiliners on hand because of occasional bouts of light bleeding, which she finds inconvenient — but much less so than an unplanned pregnancy would be!

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